The Prophet Daniel tells a famous tale of how the tyrannical king of Babylon held a feast for all his top lords and ladies, and as the feasting grew to fever pitch a mysterious hand appeared from nowhere that started writing Hebrew characters on one of the walls.
As you might suspect, this was a surprising enough event that some important wise men were called to interpret the meaning of the words, though they all failed. The only person capable of reading the words was Daniel himself and the news was not good. Very roughly there were three main learning points contained in that message; that the king’s days were numbered, that he had been judged and found wanting, and that his kingdom would be divided between the Medes and Persians. To cut a long story short, all this then took place not long afterwards.
Whilst I have not been to a feast since, possibly ever, I do feel as if I am at that same event. Every meeting I attend at my health board, at Welsh Government level and at the College in London contains variants of the same message. There are record delays for clinics, record delays for cataract surgery, record problems with trainees not getting enough cataracts to operate on and record failings in many other ways as well. We don’t produce enough homegrown consultants and Brexit and COVID-19 have hammered the chances of recruiting from abroad. So many cataracts are now being done with independent providers that unless they start allowing our trainees to operate and learn with them, we will run out of competent qualified people in the near future to do the job. In England, the genie is out of the bottle and the future cannot be planned or even envisaged without a very significant element of these private sector providers doing much of the cataract workload.
In some hospitals I learnt specific specialties are being treated the same way. I heard from one consultant working in England how a private company was coming into his department to do glaucoma clinics to get the backlog down and from another, how the same was happening with medical retina. Some consultants are now dropping NHS sessions to pick up these quasi-private sessions in their own areas to earn more whilst giving up their NHS working rights. Nurses and optometrists are doing likewise.
So, are the days of the NHS numbered? Well, all this is still free at the point of use, so superficially the answer is no. But in reality it seems the answer is yes. The NHS is meant to be much more than the people of Britain paying for healthcare through their taxes instead of when they get ill. It’s a socialistic collaborative of the best meaning best qualified people working together in unfettered harmony for the wellbeing of the nation. In theory at least. But in practice this is less obviously so.
Have we been judged and found wanting? There are many good things about the NHS and for politicians it is the most sacred of all the sacred cows. But is it good for patients? Undoubtedly it levels healthcare inequalities and boosts the quality of life of the poorest of the poor far beyond the systems of most other countries and we should be rightly proud of how people in our country are not impoverished by healthcare bills or avoid seeking care due to the cost.
But does it work well? No. Not really. Patients with diabetic eye disease develop rubeotic glaucoma whilst their appointments are massively delayed and countless thousands give up driving while waiting for cataract surgery as the waiting list is so long. The poor and destitute of the South Wales Valleys scrape together just enough cash for their mothers to attend a private cataract appointment to be told they need cataract surgery that is so exotically expensive on their terms as to make it completely out of reach. There are so many consultant vacancies in fields such as cornea that patients with complicated problems circle the healthcare system like some aeroplane waiting to land but never given clearance, while all the time the fuel is slowly and steadily running out.
The waiting times for glaucoma appointments are so long that in some parts of the country it is almost as if no glaucoma service exists at all. A person with a retinal detachment sometimes needs to travel many hundreds of miles to see a person in an institution capable of gluing it back on again in time to avoid blindness. So yes; in many respects we have been judged and found wanting. The system is far from ideal and the stress of being a moral ophthalmologist in an environment such as ours can sometimes be overwhelming. There is that old story that the single group of people most likely to suffer post-traumatic stress disorder during the first world war were those poor blighters that had to go up in tethered balloons over enemy trenches to sketch the position of their troops. The fact that they had responsibility but absolutely no means to alter their predicament or save themselves contributed to the hideously awful levels of stress they felt. We might well be those people.
The answer, indeed the only answer, is a significant investment by government in new ophthalmic infrastructure to stem the tide. Otherwise, our fate will be as that of Belshazzar the king of the Babylonians. That our kingdom will be divided between the Spamedicans and the Newmedicans. These invading forces have already taken over outlying provinces and should we ignore the threat they will be at our own doors soon. Either we as a profession collectively acknowledge the reality of the situation and join together to demand and lead change; new regional centres of excellence, non-medical practitioners working at the top of their remit in hospitals and community optometrists helping to take the load off in a fully integrated healthcare system or we will fail.
We cannot do it alone; we need politicians to realise the threat and care for the consequences. We need patients and patient advocacy groups to realise that there is a clear and present danger to their local ophthalmic unit and unless they all help then their care will be packaged and sold off to the lowest bidder. We also need to acknowledge that our own system is broken in many different ways and try and find solutions, as opposed to accepting that we are merely cogs too small to matter as we turn up to NHS lists with only four cataracts booked, of whom two are cancelled for spurious reasons; and clinics with only six patients booked per doctor.
The writing may be on the wall and visible for all who care to look, but as I understand it, Belshazzar’s father, Nebuchadnezzar, was faced with a similar situation and managed to turn it all around. The hour may be late, but it is not over yet.
The views expressed are those of the author and do not represent those of the editorial team or the publisher.
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